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Lirio S. Covey, Ph.D. David Kalman, Ph.D. Taru Kinnunen, Ph.D. Kimber Richter, Ph.D. Jill M. Williams, M.D. Nancy Kaufma

Treating Nicotine Dependence in Smokers with Mental Illness and Chemical Dependencies. Lirio S. Covey, Ph.D. David Kalman, Ph.D. Taru Kinnunen, Ph.D. Kimber Richter, Ph.D. Jill M. Williams, M.D. Nancy Kaufman, M.A. Today’s Goals. The nature of nicotine dependence

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Lirio S. Covey, Ph.D. David Kalman, Ph.D. Taru Kinnunen, Ph.D. Kimber Richter, Ph.D. Jill M. Williams, M.D. Nancy Kaufma

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  1. Treating Nicotine Dependence in Smokers with Mental Illness and Chemical Dependencies Lirio S. Covey, Ph.D. David Kalman, Ph.D. Taru Kinnunen, Ph.D. Kimber Richter, Ph.D. Jill M. Williams, M.D. Nancy Kaufman, M.A.

  2. Today’s Goals • The nature of nicotine dependence • Nicotine dependence and psychiatric co-morbidity • Smoking cessation and psychiatric disorders • Treatments

  3. Today’s Goals • The nature of nicotine dependence • Nicotine dependence and psychiatric comorbidity • Smoking cessation and psychiatric disorders • Treatments

  4. The long-standing view: Tobacco Use Is a Health Risk Factor • Cardiovascular disease • Cancer of multiple organ sites • Pulmonary Disorders • Fetal/infant/childhood morbidity & mortality through second-hand smoke

  5. Evolved view:Tobacco Use Is a More than a Risk Factor Tobacco use, in particular, chronic use of tobacco, is a disorder in itself.

  6. Nicotine Is a drug that affects functioning and structure of the brain.

  7. Nicotine Is a Drug: Neurochemical Effects of Nicotine DOPAMINE Pleasure, Appetite Suppression NOREPINEPHRINE Arousal, Appetite Suppression ACETYLCHOLINE Arousal, Cognitive Enhancement NICOTINE Mood Appetite suppression SEROTONIN VASOPRESIN Memory Improvement BETA-ENDORPHIN Reduction of Anxiety, Tension

  8. A substance dependence disorder

  9. Today’s Goals • The nature of nicotine dependence • Nicotine dependence and psychiatric disorders • Smoking cessation and psychiatric disorders • Treatments – what works?

  10. Higher prevalence of tobacco use among persons with mental illness.

  11. Multiple mental disorders are involved: Alcohol and drug dependence Depression Anxiety disorders (GAD, phobias, PTSD) Schizophrenia • Antisocial personality disorder • Conduct disorder and ADHD

  12. Smoking and Mental Illness, Lasser K et al, JAMA, 2000 • In the U.S., 20% have a lifetime history of a medical condition • 44% of all cigarette smoking done by persons with lifetime history of mental illness.

  13. Current Smokers by Mental Illness History, Lasser et al, JAMA, 2000 % 41.0 34.8 22.5 None Ever Ill Past Month

  14. Quit Rates by Mental Illness HistoryLasser et al, JAMA, 2000 42.5 37.1 30.5 None Ever Ill Past month .

  15. Prevalence of Current SmokingLasser, JAMA, 2000 % 16.9 21.5 11.4 0.6 50.7 Per cent prevalence of the condition in US population

  16. Prevalence of Current SmokingLasser, JAMA, 2000 % 4.8 6.4 11.0 6.5 50.7 Percent prevalence of the condition in the US population

  17. Major Depression Alcohol Dependence Drug Dependence Schizophrenia

  18. Major Depression • More smokers among depressed persons • More depression among smokers • Higher nicotine dependence level • Often smoke more cigarettes • Harder time quitting • More intense withdrawal symptoms • Treatments

  19. Eversmoking by MDD hx and genderSt. Louis ECA (n=3213) p<.001 p<.001 % Glassman, et al, JAMA, 1990

  20. Odds ratios for psychiatric diagnoses by nicotine dependence ,1200 adults, 21-30 yrs Substance Dep MDD Anxiety Breslau et al, 1992

  21. Major Depression • More smokers among depressed persons • More depression among smokers • Higher nicotine dependence level • Often smoke more cigarettes • Harder time quitting • More intense withdrawal symptoms • Treatments

  22. Influence of Depression History on One Year Cessation (Week 52) by Treatment Smith, Nicotine & Tobacco Research 2003

  23. Incidence of major depressive episodes in 3-month follow-up of 126 abstinent smokers p=<.001, Covey et al, Am J Psychiatry, 1997

  24. Nicotine withdrawal symptoms: intensity at week 1 after quit day p<.05 p<.01 craving irritable anxious restless appetite concentr depressed Covey et al, Comp Psychiatry,1991

  25. Major Depression • More smokers among depressed persons • More depression among smokers • Higher nicotine dependence level • Often smoke more cigarettes • Harder time quitting • More intense withdrawal symptoms • Treatments

  26. Treatments that work for smokers with Major Depression • Bupropion (Zyban) • Nortriptyline • Nicotine replacement • Mood-oriented Cognitive Behavioral Therapy

  27. Long-term quit rates among smokers with past MDD 33% 29% 15% 15% 8% 6% Smith et al, 2003 Hall et al, 1998 Kinnunen et al, 2003

  28. Recommendations • Smokers with past major depression can quit. • They will need more intensive and, possibly, longer treatments. • More information is needed for smokers who are currently depressed.

  29. Alcohol Dependence • Higher rates of current smoking • In clinical settings, 85% to 90% are smokers • Many want to quit (up to 100% in one clinical study) • Quit rates in recovering groups same as nonalcoholics • Quit rates in active drinkers lower than in nonalcoholics • No evidence of relapse to drinking upon tobacco abstinence

  30. Alcohol Dependence • Higher rates of current smoking • In clinical settings, 85% to 90% are smokers • Many want to quit (up to 100% in one clinical study) • Quit rates in recovering groups same as nonalcoholics • Quit rates in active drinkers lower than in nonalcoholics • No evidence of relapse to drinking upon tobacco abstinence

  31. Alcohol Dependence • Higher rates of current smoking • In clinical settings, 85% to 90% are smokers • Many want to quit (up to 100% in one clinical study) • Quit rates in recovering groups same as nonalcoholics • Quit rates in active drinkers lower than in nonalcoholics • No evidence of relapse to drinking upon tobacco abstinence

  32. What treatments work for Alcohol Dependent smokers? • Bupropion (Zyban) same results as for nonalcoholic smokers • Nicotine replacement agents • Cognitive behavioral treatment for mood management helps alcoholic smokers with history of major depression • 12-step program enhanced effect of standard counseling treatment

  33. How effective is smoking cessation treatment for smokers in recovery? Over 25 studies to date Most studies focused on either smokers in early recovery (< 3 months) or later recovery (> 1 year) Treatment included behavioral counseling and medication (nicotine replacement, bupropion) Rates of successful quitting about 10% for smokers in early recovery about 25% for smokers in later recovery

  34. How effective is smoking cessation treatment for smokers in recovery?

  35. Effect of Trying to Quit Smoking on Sobriety, Joseph et al, 2003 499 smokers in alcohol dependence treatment Smoking treatment (counseling + NRT) Concurrent or delayed (6 months) Outcomes - smoking and drinking status

  36. Outcomes at 12 months from concurrent smoking and alcohol treatment, Joseph et al, 2003

  37. Smoking Abstinence (7-day Point Prevalence) by Nicotine Patch Dose (N=130), Kalman, 2002

  38. 7-day point prevalence quit rates by length of abstinence from alcohol (N=130), Kalman, 2002

  39. Future Research Factors affecting smoking cessation outcomes for alcoholics in early recovery Saturated social network of smokers? Combination pharmacotherapies (e.g., bupropion plus naltrexone) More frequent smoking cessation counseling.

  40. Drug Dependence • High rates of current smoking • 70% in cannabis dependent • 75% in cocaine dependent • 85%-98% in methadone-maintained • Extremely high levels of nicotine dependence • Claim that quitting smoking is hardest • Strong levels of interest in quitting

  41. Drug Dependence • High rates of current smoking • 70% in cannabis dependent • 75% in cocaine dependent • 85%-98% in methadone-maintained • Extremely high levels of nicotine dependence • Claim that quitting smoking is hardest • Strong levels of interest in quitting

  42. Drug Dependence • High rates of current smoking • 70% in cannabis dependent • 75% in cocaine dependent • 85%-98% in methadone-maintained • Extremely high levels of nicotine dependence • Claim that quitting smoking is hardest • Strong levels of interest in quitting

  43. Drug Dependence • High rates of current smoking • 70% in cannabis dependent • 75% in cocaine dependent • 85%-98% in methadone-maintained • Extremely high levels of nicotine dependence • Claim that quitting smoking is hardest • Strong levels of interest in quitting

  44. Limited knowledge base on smoking cessation treatments for smokers with drug dependence. • Specially needed are studies that will clarify the bidirectional dynamic between tobacco dependence and drug dependence. • Review paper, Sullivan and Covey, Current Psychiatry Reports, 2002

  45. Methadone – Great Place to StartRichter, 2003 • Medically oriented, not anti-pharmacotherapy • Patients get stable, can think long-term • Many patients are over 30 - many start having tobacco-related illnesses, so do friends • Patients stay in treatment for long periods, visit clinics regularly, develop relationships with staff • Methadone has consistent treatment guidelines and a strong national network (good for dissemination)

  46. How to Start? • What are the best treatments? • When to treat? • What do patients want/have tried? • How to prevent relapse to other drugs? • What are providers doing now? • What do they find works best? • Etc.

  47. Percent service provided to at least 1 patient in the Past 30 Days % Providing service to at least 1 patient Zyban NRT Groups Brief Advice Counseling Referral Brochure Acupunct.

  48. Staff not trained (118) Patients not interested (111) Other drug treatment more important (78) Not enough staff (58) Clinic does not receive reimbursement (49) Staff are too busy (36) Staff smoke cigarettes (20) Smoking treatment is ineffective (7) Other (33) Most Important Barrier to Providing Smoking Cessation Services, Richter, 2003

  49. Lessons Learned • There ARE barriers to offering services • #1 is lack of staff training • #2 is perception that patients aren’t interested • There are also BENEFITS to offering services • Improve health, outcomes, cleanliness • Few clinicians actively discourage/delay quitting • Perceptions that some patients appear to benefit from smoking (may explain why cessation treatment is not always offered?)

  50. Recommendations • Regulatory agencies could require/encourage clinics to in some way address nicotine addiction among stable patients • Methadone clinics need to offer Nicotine Dependence Treatment Training! • Find clinics that are already doing it, empower them to disseminate programs • Address benefits of tobacco use and alternate treatments for mood disorders

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